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By W. Mezir. South Dakota State University. 2018.

Diagnosis EMG Imaging Differential diagnosis L2–L4 radiculopathy Therapy Depends on etiology and type of nerve injury Prognosis Depends on etiology and type of nerve injury References Roger LR remeron 15mg for sale, Borkowski GP buy cheap remeron 15mg on-line, Albers JW buy remeron 15 mg visa, et al (1993) Obturator mononeuropathy caused by pelvic cancer: six cases purchase remeron 30 mg. Neurology 43: 1489–1492 Sorenson EJ discount remeron 15mg free shipping, Chen JJ, Daube JR (2002) Obturator neuropathy: causes and outcome. Muscle Nerve 25: 605–607 Staal A, van Gijn J, Spaans F (1999) The obturator nerve. In: Staal A, van Gijn J, Spaans F (eds) Mononeuropathies; examination, diagnosis and treatment. Saunders, London, pp 109–111 213 Femoral nerve Genetic testing NCV/EMG Laboratory Imaging Biopsy + Fig. Femoral nerve lesion after vascular surgery Anatomy The femoral nerve is derived from the lumbar plexus (originating from the ventral roots of L2–L4). Proximal (intrapelvic) branches go to the psoas major and iliacus muscles, passing through the inguinal ligament. Motor branches go to the pectineus, sartorius and quadriceps muscles. Sensory branches to the medial aspect of the thigh, anterior medial knee, and lower leg (saphenous nerve) (see Fig. Symptoms Sensory loss on the ventral thigh, perhaps with saphenal involvement (over the tibial bone). Buckling of the knee (on uneven surfaces) and falls (leg “collapses”). Pain is variable, depending on the cause of the neuropathy. Nerve trunk pain with or without sensory symp- toms (e. Clinical syndrome Atrophy and weakness of quadriceps muscles. Weakness of the psoas and quadriceps muscles only occurs with proximal lesions. Sensory loss over anterior aspect of thigh and medial side of lower leg. Causes Compressive: Compression or stretch during surgery or obstetrical procedures: hip arthroplas- ty, pseudoaneurysm in the groin, retraction in abdominal surgery, vaginal hysterectomy in lithotomy position, laproscopic hernia repair, kidney trans- plantation, abdominal hysterectomy, vaginal delivery (see Fig. Neoplastic: local tumors, perineuroma, malignant invasion Traumatic: Penetrating injury Vascular: Anticoagulant therapy Hematoma in psoas or iliacus muscle from rupture of an abdominal aortic aneurysm Trauma Saphenous nerve lesions: Bursitis of pes anserinus Entrapment, medial side of knee Entrapment by a branch of the femoral artery Meniscectomy, arthroscopy Neurolemmoma EMG: quadriceps and iliac muscles, include paraspinal, iliopsoas, hip adductor Diagnosis NCV: femoral nerve latencies and CMAPs Sensory nerve conduction of the main trunk difficult Sensory nerve conduction of saphenal nerve Saphenous SEP (stimulation inferomedial to patella) is more reliable. Neuroimaging: CT scan for psoas hematoma (has to be done acutely if hemato- ma is suspected) or tumor infiltration of psoas muscle MRI-femoral nerve tumors Laboratory tests: fasting glucose, vasculitis serologies Aneurysm of iliac artery Differential diagnosis Irradiation of the inguinal area L2–L4 radiculopathy Mononeuropathy multiplex Depends on the etiology. Therapy Complete, postoperative lesions require surgical approach. Surgery is also indicated for hematoma, depending upon the location and size. In: Vinken PJ, Bruyn GW (eds) Handbook of clinical neurology. American Elsevier, New York, pp 303–310 Busis NA (1999) Femoral and obturator neuropathies. Neurol Clin 17: 633–653 Kim DH, Kline DG (1995) Surgical outcome for intra- and extrapelvic femoral nerve lesions. J Neurosurg 83: 783–790 Kuntzer T, Van Melle G, Regli F (1997) Clinical and prognostic features of femoral neuropathies. Muscle Nerve 20: 205–211 Mark MD, Kwasnik EM, Wright SC (1990) Combined femoral neuropathy and psoas sign: an unusual presentation of iliac artery aneurysm. Am J Med 88: 435–436 Simmons Z, Mahadeen ZI, Kothari MJ, et al (1999) Localized hypertrophic neuropathy; magnetic resonance imaging findings and long term follow up. Muscle Nerve 22: 28–36 217 Saphenous nerve Genetic testing NCV/EMG Laboratory Imaging Biopsy + The saphenous nerve is one of three sensory branches of the femoral nerve. Anatomy (The others being the medial and intermediate femoral cutaneous nerves. Numbness, but also severe neuropathic pain may occur.

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He suggests that when needs are assessed the focus should be on the whole 70 / BROTHERS AND SISTERS OF CHILDREN WITH DISABILITIES family purchase remeron 15mg mastercard, and not on individuals in isolation 30mg remeron otc. To achieve such an objective remeron 30mg on-line, researchers should understand how families experience their caring responsibilities purchase remeron 15mg on-line. My research (Burke and Montgomery 2003) supports the fact that siblings help their brothers and sisters buy remeron 30 mg without a prescription, exceptionally where there is a disability. The nature of that help extends beyond the spectrum of help offered by others who are free from major disabilities or conditions because it is the conditions themselves which impose the additional need for caring. This is not contentious, but it is indicative of a need for increased support for those requiring additional services. A number of themes explored in my research were noted from 22 interviews with families and children. Additionally, notes were taken at two sibling-led support group meetings, in an attempt to see whether themes identified within the original interviews were recurrent or isolated, this being a form of research triangu- lation to improve the reliability of the findings (see Chapter 2: Part 2, for a more detailed discussion on research methods). In the survey questionnaire, distributed to 115 families, of the 56 replies, 82 per cent of families (45 out of 55) answered the question ‘Do your non-disabled children help you with the care of their disabled brother or sister? It appears then, according to parents, that the majority of siblings helped in some way with caring needs of their disabled brother or sister. According to 16 siblings interviewed, all said they helped their family with differing types of caring tasks. The nature of those responsibilities will now be explained in more detail. Relieving the stress experienced by parents Siblings may help by taking pressure off their parents. Siegal and Silverstein (1994) also identified that when children take on a parental role they reduce the stress experienced by the main carers, usually the parents. Through being a care-giver as well as a son or daughter the child forms an alliance with their parents which, according to Mayhew and Munn (1995), gives them added status within the family. CHILDREN AS YOUNG CARERS / 71 In interview, with a girl I shall call Katy, aged 13, she recalled how she would assist her parents, by reading a story to her brother as part of his bedtime routine. Another girl, Jackie, aged 14, acknowledged that she thought it part of her responsibility to take the pressure off her parents by giving her brother her attention, thereby diverting his demands away from both parents. Chris, aged 14, would play with his sister, Mary, who had ‘autistic tendencies’ and would usually suffer his hair being pulled, but would not react by shouting or showing any indication of pain, having discovered that reacting encouraged more hair pulling. He never discussed this with his parents because ‘they had enough to worry about’. He helped his parents by keeping his sister occupied, tolerating her behaviour in a way he would never accept from his friends and by not telling his parents about the stress Mary caused him. The motivation to take on the role as helper may not therefore be to gain parental approval; it may be an acceptance of one’s situation within the family. The problem is that such encounters may well instil a sense of guilt at having similar abilities to most other children, a fact which others would never question. These examples demonstrate a form of disability by association, acceptance perhaps, from which ‘young carers’ would normally exclude their parents, but would ‘only tell’ because of ‘the research interview’. A further insight, one that helps to explain the reticence of siblings to express their opinions, is offered by Bank and Kahn (1982), who point out that, when one sibling is viewed as disabled, the non-disabled sibling will try and refrain from aggressive behaviour. The difficulty associated with this apparent ‘good behaviour’ is that the spontaneity of child play, including ‘messing about’, will be inhibited (Ibid. Siblings may also be ashamed of or embarrassed by their disabled sibling and learn not to speak out, rather keeping their views to themselves, as this review 72 / BROTHERS AND SISTERS OF CHILDREN WITH DISABILITIES has demonstrated. Consequently, it is not too surprising when Powell and Ogle (1985) note that siblings may feel confused about their role within the family, for they are both sibling and carer, playmate and responsible person, but without the maturity of an adult. Life restrictions In a survey carried out by Atkinson and Crawford (1995) for NCH Action for Children, seven out of ten children surveyed said their caring responsi- bilities placed restrictions on their lives. Richardson (1999), a brother with a disabled sister, could not remember being cared for himself; as he put it, ‘ I don’t much recall being looked after’. His family had to focus on the needs of his disabled sister, as he did himself. The consequences of having a disabled sibling are not all positive and I note adverse aspects too: for example, Janet aged 13, who has a sister with disabilities, said, ‘I really do love my brothers and sister but they get so annoying I feel like crying’ (Burke and Montgomery 2001b, p. Powell and Ogle (1985) suggest that siblings may feel confused about their role in the family, being both sibling and ‘surrogate parent’.

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Over the past few months discount 15 mg remeron fast delivery, he has been drinking alcohol more often cheap 15mg remeron visa, has received a traffic citation for driving under the influence of alcohol buy generic remeron 30 mg on-line, and has missed days of work order 15mg remeron mastercard. Which of the following statements regarding the Diagnostic and Statistical Manual of Mental Disorders—Text Revision (DSM-IVTR) definition of dependence is false? Tolerance and withdrawal are criteria for dependence B buy cheap remeron 15mg on-line. Dependence disorders encompass psychiatric states that resemble primary psychiatric syndromes but that occur only during periods of intoxication or withdrawal from a substance C. The inability to cut back when needed is a criterion D. Continued use of a substance despite problems is a criterion Key Concept/Objective: To understand the definition of dependence The DSM-IV defines dependence as a condition of repetitive and intense use of a sub- stance that results in repeated problems in at least three of seven areas of concern. Those problems must all occur within the same 12-month period. The categories of problems include tolerance and withdrawal (with the presence of either one justifying a diagno- sis of dependence with a physiologic component), difficulty controlling use, an inabil- ity to cut back when needed, spending a lot of time taking the substance, failing to take part in important events to use the substance, and continuing use despite problems. In effect, the last of these indicates that the substance means more to the person than the problems it is causing. Substance-induced disorders encompass psychiatric states that resemble primary psychiatric syndromes (e. Substance-induced disorders improve rapidly and resolve completely with- in a few days or a month of stopping the use of the substance and can usually be treat- ed with education, reassurance, and a cognitive-behavioral approach. A 36-year-old woman enters the emergency department stating, “I just took too many pills. Which of the following statements regarding the overdose of drugs of abuse and the management of overdose is false? A mild overdose with no significant change in vital signs is called intoxication and can be managed conservatively by putting the patient in a quiet room with a friend or relative B. An overdose of a stimulant can cause tachycardia, cardiac arrhyth- mias, hypertension, hyperthermia, and seizures C. Benzodiazepine overdose commonly causes pulmonary edema D. Opioid overdose can cause life-threatening decreases in respiratory rate, heart rate, and blood pressure E. Therapy for stimulant overdose can include intravenous benzodi- azepines, cooling blankets, and intravenous nitroprusside Key Concept/Objective: To understand common overdose states and their treatments Intoxication involves changes in vital signs and alterations in mood and cognitive function caused by a drug. Provided that the vital signs are relatively normal, treatment of intoxication consists of controlling behavior by placing the person in a quiet room; having a friend or relative stay with the person, if possible; offering reassurance; and employing the judicious use of low doses of appropriate medications (e. Overdoses are intoxications of such severity as to produce life-threatening changes in vital signs. As such, overdoses must be managed in an emer- gency department or an inpatient setting. Treatment begins with provision of general medical and psychological support, with an emphasis on normalizing vital signs and allowing the body to metabolize the drug. Depending on the drug category and the clinical manifestations, specific pharmacologic treatment may be indicated. Overdoses with stimulants typically produce tachycardia, cardiac arrhythmias, and potentially life-threatening elevations in blood pressure and body temperature; seizures may also occur. Treatment includes administration of intravenous fluids; administration of intra- venous benzodiazepines for seizures; use of cooling blankets to control hyperthermia; and administration of intravenous phentolamine or nitroprusside for blood pressure control. High doses of opioids produce life-threatening decreases in respiratory rate, heart rate, and blood pressure; pulmonary edema or coma are possible. Patients who have overdosed on benzodiazepines are treated with general supportive measures and an intravenous infusion of the antagonist flumazenil. A 49-year-old man who has a documented history of multiple substance abuse is brought to the emer- gency department after being "found down. After speaking with his family, it becomes evident that he is in a drug withdrawal state. Which of the following statements regarding withdrawal states from drugs of abuse is false?

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Findings of elevated central pressures in the absence of other signs of congestive heart failure are very helpful order remeron 30 mg free shipping. In contrast to cardiac tamponade safe remeron 15mg, paradoxical pulse is present generic remeron 15 mg with amex, and the Kussmaul sign can occasionally be seen discount 15 mg remeron with visa. A 26-year-old woman is being evaluated for dyspnea remeron 30mg low cost, which she experiences when she engages in phys- ical activity. She has been having these symptoms for the past 4 months. She denies having chest pain, orthopnea, or paroxysmal nocturnal dyspnea. The patient’s medical history is significant for her having one episode of atrial fibrillation 1 month ago. Her physical examination shows fixed splitting of S2 and a 2/6 systolic murmur in the pulmonic area. An electrocardiogram shows mild right axis deviation and an rSR’ pattern in V1. A chest x-ray reveals an enlarged right atrium and main pulmonary artery. Which of the following is the most likely diagnosis for this patient? Dextrotransposition of the great arteries Key Concept/Objective: To be able to recognize an ASD ASDs occur in three main locations: the region of the fossa ovalis (such defects are termed ostium secundum ASDs); the superior portion of the atrial septum (sinus venosus ASDs); and the inferior portion of the atrial septum near the tricuspid valve annulus (ostium pri- mum ASDs). The last two are considered to be part of the spectrum of AVSDs. Ostium secundum ASDs are the most common variety, accounting for over half of ASDs. Most patients with ostium secundum ASDs are asymptomatic through young adulthood. As the patient reaches middle age, compliance of the left ventricle may decrease, increasing the magnitude of left-to-right shunting. Long-standing atrial dilatation may lead to a variety of atrial arrhythmias, including atrial fibrillation. A substantial number of middle-aged patients report dyspnea. The hallmark of the physical examination in ASD is the wide and fixed splitting of the second heart sound. A systolic murmur (from increased pulmonary flow) is common. On electrocardiography, the QRS axis is usually normal in patients with ostium secundum ASD but may be slightly rightward, and an rSR’ pattern is common in the right precordial leads. The chest x-ray reveals an enlarged right atrium, right ventricle, and main pulmonary artery. AVSDs include a complex spectrum of disorders involving abnormalities of the atrioventricular septum and, frequently, the atrioventricular valves. Patients with AVSDs can present with symptoms and physical findings similar to patients with ostium secundum ASD. An addi- tional pansystolic murmur can be found in patients with a complete AVSD. Left axis devi- ation is present in the majority of patients with AVSD; in contrast, right axis deviation is found in patients with ostium secundum ASD. The classic physical finding of a VSD is a harsh pansystolic murmur, heard best at the left lower sternal border. Electrocardiography may be normal or show evidence of left ventricular hypertrophy and a pattern of diastolic overload. Dextrotransposition of the great arteries is a cyanotic congenital cardiopathy. Survival beyond the first year without surgical repair is uncommon. A 35-year-old man presents to a hospital with fatigue and fever of 3 weeks’ duration. When giving his medical history, he reports that he has had a “heart murmur” since birth.

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His mother had a subarachnoid hemorrhage at 54 years of age buy remeron 15 mg. He has no personal history of hypertension remeron 15 mg visa, vascular disease buy remeron 30mg lowest price, or elevated cholesterol levels buy 30mg remeron with visa. His examination reveals a blood pressure of 148/84 mm Hg and mild nuchal rigidity buy remeron 15 mg online. A CT scan of the head fails to reveal an abnormality. What is the best step to take next in the management of this patient? Carotid Doppler examination Key Concept/Objective: To understand that CT scanning of the brain is not 100% sensitive in excluding subarachnoid hemorrhage (SAH) This patient presents with many of the classic findings of acute subarachnoid hemorrhage, including the sudden onset of a severe headache, diminished level of consciousness, and nuchal rigidity. Family history of aneurysm is present in about 4% of patients with SAH. Establishing the diagnosis early is necessary to improve long-term morbidity and mortal- ity. It is important to note that CT scanning of the head is not 100% sensitive in exclud- ing this “high-stakes” entity. In the presence of clinical suspicion and a negative imaging study, a lumbar puncture is necessary to look for the presence of xanthochromia and RBCs. A 55-year-old man presents to the emergency department with sudden onset of tachycardia and light- headedness. He has had no previous episodes of similar symptoms. He has a history of hypertension con- trolled with amlodipine. His examination reveals a blood pressure of 132/82 mm Hg and an irregular heart rate of 120 beats/min. His lung examination is normal, and his cardiac exam- ination reveals an irregular rhythm, with no obvious murmur or extra sounds and S1 having variable intensity. An ECG reveals atrial fibrillation and left axis deviation. An echocar- diogram reveals normal left ventricular systolic and diastolic function and no thrombus or valvular abnormalities. Which of the following drugs would you give this patient to minimize the long-term risk of throm- boembolism? Low-molecular-weight heparin Key Concept/Objective: To understand that patients younger than 65 years who are without risk factors are at low risk for thromboembolism from atrial fibrillation Risk factors such as hypertension, diabetes, previous CVA/TIA, and poor LV function, along with older age (> 65 years), are associated with a yearly risk of thromboembolism from atri- al fibrillation of approximately 5%. This risk can be decreased to approximately 1% with warfarin and 2% to 3% with aspirin. The risk of thromboembolism is 1% without therapy in patients without risk factors and younger than 65 years. This patient has a history of controlled hypertension and has a normal echocardiogram, which decreases the probabil- ity that his hypertension has caused end-organ complications. He has no other risk factors 14 BOARD REVIEW for thromboembolism caused by his atrial fibrillation and likely has “lone atrial fibrilla- tion. Ticlopidine or newer antiplatelet agents may be of benefit when aspirin has failed. In addition, converting patients to sinus rhythm: either with electrical cardioversion or chemically: is a desirable outcome in such situations. Finally, agents to control ventricular rate (beta blockers, diltiazem, or digoxin) should be considered in this patient. A 24-year-old man is brought to the emergency department by the emergency medical service (EMS). He suffered head trauma 20 minutes ago while playing football. Immediately after the event, he lost con- sciousness for 3 minutes and then woke up mildly confused. On physical examination, the patient’s vital signs are stable, his Glasgow Coma Scale (GCS) score is 15, and he has no focal signs on neurologic examination. What interventions would be appropriate in the treatment of this patient? Continue with observation and repeated neurologic examinations; repeat assessment with the GCS periodically; and consider imaging with a CT scan to rule out contusions B.

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